Medicine case
Name :- Lakshmi Manvitha Yechuri
Roll no :- 169
Introduction :
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A 24 yr old male labour by occupation resident of Nalgonda has come to the hospital
Chief complaints : -
Fever since 1 week
Stomach pain since 1 week
And black colored stools since 2 days
Giddiness since 1 days
Patient daily routine :-
He gets up in the morning at 7:30am and has his breakfast and go to work which is labour at 8:30 am he returns back home at 6pm has his dinner and go to sleep at 10pm
He had gone to a function and next day he noticed fever.
History of present illness :-
The patient was apparently asymptomatic 1 week ago , later he then developed high grade fever which is of intermittent type insidious in onset gradually in progression associated with chills during the night time for 2 days , the fever would be moderate during the daytime .
He visited a local RMP and used medication(injection) for 3 days and the fever subsided.
Stomach pain since 1 week
Site entire abdomen
Onset- insidious
Gradually in Progression
Duration 1 week
Type which is uncomfortable bloating
Radiating the pain shift to his right chest when he sleeps to his left side
Aggravating on taking food
relieving on medication
The stomach pain is not associated with vomitings or any loose stools or constipation
H/ O black coloured stools since 2 days
H/ O giddiness since 1 day
the patient was admitted to our hospital on 11/12/21
He developed a itchy scaly skin lesions on his left cheek since 1 day
No H/O headache , vomitings , loose stools , body pains , burning micturition or cough rashes or body pains
Past History :-
No similar complaints in the past
No H/ O HTN, DM , Asthma , TB , Epilepsy
Personal History :-
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel movements - normal , bladder movements
Addictions no
No known allergies
Family history :-
No significant family history
GENERAL EXAMINATION :-
Patient was conscious , coherent and cooperative moderately built , he was examined in a well lit room after having taken his consent
No signs of pallor , icterus , clubbing , cyanosis , lymphadenopathy or oedema
VITALS :- Temperature -98.3 F
Pulse rate - 98 bpm
Respiratory rate - 20 cpm
BP -130/80 mm of Hg
SpO2 - 98 % at RA
SYSTEMIC EXAMINATION :-
CVS :- S1, S2 heard
No thrills or murmurs noted
Respiratory system :- BAE +
Normals vesicular breath sounds heard
Trachea is central in position
No wheezing or dyspnoea present
Per abdominal examination :-
ABDOMEN-
On Inspection:
Shape of the abdomen - scaphoid
No visible scars,orifices
On Palpation:
Soft and non tender
No palpable mass
Liver and spleen not palpable
On percussion:
Dull note is seen
On auscultation:
Bowel sounds heard
Soft , non tender , no evidence of organomegaly
No palpable masses , free fluid noted
Bowel sounds heard
CNS examination :-NAD
Patient's clinical images :-
Investigations :-
X-ray:
USG :
RBS:
Hemogram :-
Liver function test :
Fever chart
Detection of IgG and IgM antibodies
Provisional diagnosis :- Dengue fever with thrombocytopenia ( NS + )
Treatment :-
(11/12/2021)
1) IVF NS,RL,DNS- @100 ml/hr.
2) Inj pantop 40 mg IV OD
3) W/F postural hypotension, bleeding manifestations
4) tab doxycycline 100 mg po BD
5) Inj optineuron 1 amp IV OD in 100 ml DNS
6) BP,PR 4th hourly
7) Temp charting 4th hourly
8) GRBS 12th hourly.
(12/12/2021):-
IVF NS,RL,DNS- @100 ml/hr.
Inj pantop 40 mg IV OD
doxycycline 100 mg po BD
Inj optineuron 1 amp IV OD in 100 ml DNS
BP,PR 4th hourly
Temp charting 4th hourly
GRBS 12th hourly.
(13/12/2021):-
IVF NS,RL,DNS- @100 ml/hr.
Inj pantop 40 mg IV OD
doxycycline 100 mg po BD
Inj optineuron 1 amp IV OD in 100 ml DNS
BP,PR 4th hourly
Temp charting 4th hourly
GRBS 12th hourly.
(14/11/21):-
IVF NS,RL,DNS- @100 ml/hr.
Inj pantop 40 mg IV OD
doxycycline 100 mg po BD
Inj optineuron 1 amp IV OD in 100 ml DNS
BP,PR 4th hourly
Temp charting 4th hourly
GRBS 12th hourly.
On 16/12/2021
Dermatology consultation
It is a known case of dengue fever with thrombocytopenia complaint of itchy scaly skin lesion on left side of face, beard since 1 day
no history of application of any topical medication
no history of similar complaints in the family
On examination
multiple well defined erythematosis scaly annular plaques on right cheek beard area tinea faciei
Treatment
Lulican cream BD for two weeks
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